Explanatory Variable | Sending Information to Specialist Marginal Effect (P Value) | Receiving Information From Specialist Marginal Effect (P Value) | ||
---|---|---|---|---|
Track 1 | Track 2 | Track 1 | Track 2 | |
Characteristics of beneficiaries attributed to primary care physician | ||||
Percentage of beneficiaries with specific characteristica,b | ||||
Age category, y | ||||
<65 | 0.005 (.09) | 0.005 (.06) | 0.003 (.35) | –0.004 (.18) |
65-74 (reference) | NA | NA | NA | NA |
75-84 | 0.003 (.09) | 0.005c (.01) | –0.001 (.68) | 0.002 (.37) |
≥85 | 0.001 (.8) | 0.001 (.58) | 0.003 (.25) | –0.001 (.61) |
Race category | ||||
White (reference) | NA | NA | NA | NA |
Black | 0 (.74) | 0.002 (.08) | 0.003c (<.001) | 0 (.83) |
All other/unknown | –0.001 (.41) | 0.002 (.11) | 0.001 (.38) | 0 (.88) |
Male | 0.002 (.1) | 0.001 (.22) | 0.004c (<.001) | 0 (.9) |
Original Medicare eligibility categories | ||||
Age (reference) | NA | NA | NA | NA |
Disability only | –0.006d (.03) | –0.008c (<.001) | –0.002 (.52) | 0.003 (.38) |
ESRD only or ESRD with disability | –0.018 (.08) | –0.002 (.84) | –0.004 (.74) | 0.008 (.46) |
Indicator for dual status | 0.003d (.02) | 0.001 (.48) | –0.001 (.5) | 0.001 (.38) |
Reversed Bice-Boxerman Index ≥0.85e | –0.001 (.31) | 0 (.93) | 0.002d (.03) | 0.002 (.06) |
Average beneficiary risk for subsequent expendituresa | ||||
HCC scoref | –0.184 (.3) | 0.027 (.88) | 0.203 (.37) | 0.246 (.2) |
Characteristics of primary care physician | ||||
Age categories, yg | ||||
≤50 (reference) | NA | NA | NA | NA |
>50 | –0.012 (.51) | 0.037 (.07) | 0.1c (<.001) | 0.069c (<.001) |
Malef | –0.025 (.46) | –0.033 (.34) | –0.064 (.1) | 0.031 (.42) |
Specialtyg | ||||
Family medicine (reference) | NA | NA | NA | NA |
General practice | –0.054 (.6) | –0.133 (.5) | 0.045 (.64) | –0.189 (.15) |
Internal medicine | –0.001 (.95) | –0.047 (.05) | –0.057d (.04) | –0.032 (.21) |
Time in direct patient careh | –0.095 (.27) | –0.04 (.61) | 0.053 (.57) | 0.043 (.63) |
Comprehensiveness measures | ||||
Range of services measure: assesses the comprehensiveness of services that a physician provided to Medicare fee-for-service beneficiariesh | 0.007 (.53) | 0.005 (.61) | 0.01 (.43) | –0.007 (.57) |
New problem management measure: assesses extent to which a physician manages patients’ new symptoms or problems instead of referring them to (or the patients seeking) a specialisth | –0.296 (.17) | 0.187 (.35) | –0.148 (.55) | 0.554d (.02) |
Involvement in patient conditions measure: assesses extent to which a physician is involved in the care of the broad range of their patients’ health conditionsh | 0.236d (.03) | 0.107 (.28) | 0.118 (.35) | 0.009 (.94) |
Characteristics of primary care practice site, including market characteristics | ||||
CPC+ practice site (vs comparison site)i | 0.036 (.07) | 0.013 (.5) | 0.026 (.24) | 0.005 (.82) |
Practice site has ≥1 NP or PAh | –0.004 (.87) | –0.016 (.46) | –0.012 (.64) | 0.036 (.17) |
Number of total practitioners (any specialty)i,j | –0.002d (.05) | 0 (.77) | –0.001 (.56) | –0.002d (.05) |
Number of practitioners at practice site with primary care specialtyi,j | ||||
Small (1-2 primary care practitioners) (reference) | NA | NA | NA | NA |
Medium (3-5 primary care practitioners) | 0.021 (.46) | 0.012 (.69) | –0.042 (.19) | –0.026 (.43) |
Large (≥6 primary care practitioners) | 0.016 (.67) | –0.001 (.99) | –0.014 (.74) | 0.002 (.97) |
Practice site is multispecialty vs primary care onlyi | –0.038 (.21) | –0.032 (.25) | 0.07d (.03) | 0.016 (.6) |
Hospital or health system owns the practice sitei | –0.029 (.17) | –0.046d (.02) | 0.051d (.04) | 0.12c (<.001) |
Whether practice participated in an a Shared Savings Program ACOk | ||||
Did not participate in Shared Savings Program (reference) | NA | NA | NA | NA |
Shared Savings Program Track 1 | –0.044d (.03) | –0.05d (.02) | –0.015 (.52) | –0.019 (.42) |
Shared Savings Program Track 2 or 3 | 0.001 (.98) | –0.006 (.89) | –0.016 (.76) | –0.062 (.21) |
Primary care transformation experience: NCQA, TJC, AAAHC, URAC, or state medical-home recognition status (whether practice is in a medical home) or participated in CPC Classic or MAPCPl | 0.017 (.42) | 0.013 (.57) | 0.036 (.13) | 0.02 (.42) |
Meaningful EHR usem | ||||
Did not meet meaningful use criteria (reference) | NA | NA | NA | NA |
Met meaningful use criteria 2011-2012 | 0.008 (.82) | 0.027 (.66) | 0.06 (.17) | 0.065 (.26) |
Met meaningful use criteria 2013-2015 | 0.048 (.25) | 0.114 (.07) | 0.062 (.21) | –0.008 (.91) |
Practice after hours (number of weekdays practice is open after 5 pm and whether practice is open Saturday or Sunday)i | 0.004 (.45) | –0.004 (.46) | 0.004 (.52) | 0.008 (.15) |
US Census regioni,n | ||||
Northeast (reference) | NA | NA | NA | NA |
Midwest | 0.042 (.2) | –0.036 (.22) | 0.016 (.63) | 0.097c (.01) |
South | 0.125c (<.001) | 0.022 (.6) | –0.094 (.08) | 0.07 (.17) |
West | 0.053 (.18) | 0.01 (.79) | 0.038 (.37) | 0.044 (.32) |
Median household income of countyo | 0 (.28) | 0c (.01) | 0 (.48) | 0 (.44) |
Practice site in a county Health Professional Shortage Area in 2015-2016o | 0.012 (.92) | 0.107 (.14) | 0.159d (.04) | –0.068 (.46) |
Urbanicity of practice site countyo | ||||
Urban (reference) | NA | NA | NA | NA |
Rural | 0.071 (.1) | 0.092d (.04) | –0.051 (.36) | –0.02 (.71) |
Suburban | 0.036 (.27) | 0.068d (.03) | –0.011 (.76) | 0.038 (.26) |
Percentage of adults age ≥25 years in the county with a degree from a 4-year collegeo | –0.002 (.3) | 0.002 (.38) | 0.002 (.51) | –0.002 (.38) |
Percentage of county’s population in povertyo | –0.003 (.56) | –0.005 (.32) | 0.003 (.55) | –0.009 (.07) |
Number of hospital beds per 1,000 in practice site countyo | ||||
Quartile 1 (reference) | NA | NA | NA | NA |
Quartile 2 | –0.009 (.76) | –0.009 (.75) | –0.027 (.37) | –0.003 (.92) |
Quartile 3 | –0.041 (.2) | –0.002 (.94) | –0.058 (.1) | 0.025 (.52) |
Quartile 4 | –0.056 (.19) | –0.093d (.02) | –0.094d (.04) | 0.02 (.67) |
2015 Medicare Advantage penetration rate in countyo | 0.002d (.05) | 0.001 (.35) | 0.002 (.07) | 0.004c (<.001) |
Number of assigned beneficiariesa | 0 (.09) | 0 (.38) | 0 (.4) | 0 (.49) |
Hospital Referral Region Price Index in 2015: measures actual per capita costs on Medicare Parts A and B relative to standardized per capita costsp | –0.081 (.68) | –0.032 (.88) | –0.12 (.6) | 0.37 (.13) |
Ratio of PCPs to total physicians in the countyo | 0.299 (.14) | 0.235 (.2) | 0.357 (.06) | 0.396d (.02) |
Number of practitioners per 100,000 residents in the county in 2016o | 0 (.15) | 0 (.55) | 0c (.01) | 0c (<.001) |
PCPs, No. | 2,244 | 2,418 | 2,273 | 2,448 |
Adjusted R-squared | 0.12 | 0.11 | 0.06 | 0.07 |
AAAHC = Accreditation Association for Ambulatory Health Care; ACO = accountable care organization; CMS = Centers for Medicare and Medicaid Services; CPC+ = Comprehensive Primary Care Plus; EHR = electronic health record; ESRD = end-stage renal disease; HCC = hierarchical condition category; MAPCP = multipayer advanced primary care practice; NA = not applicable; NCQA = National Committee for Quality Assurance; NP = nurse practitioner; PA = physician assistant; PCP = primary care physician; TJC = The Joint Commission; URAC = Utilization Review Accreditation Commission.
Note: Models estimated using logistic regression, where dependent variable is 1 if survey response is “Always or most of the time” and 0 otherwise.
↵a All beneficiary characteristics come from Medicare fee-for-service claims and enrollment data. They are measured as of the end of 2016 (before CPC+ began).
↵b The following individual HCCs were also included in the regression model but are not reported: HCC 8-Metastatic Cancer/Acute Leukemia; HCC 18-Diabetes with Complications; HCC 21-Malnutrition; HCC 22-Morbid Obesity; HCC 23-Endocrine/Metabolic Disorders; HCC 40 or 47-Rheumatoid Arthritis; HCC 46 or 48-Severe Hematological Disorders; HCC 54 or 55-Drug/Alcohol Psychosis or Dependence; HCC 57 or 58-Schizophrenia or Major Depressive Disorders; HCC 70 or 71-Quadriplegia or Paraplegia; HCC 80 or 82-Coma; HCC 85-Congestive Heart Failure; HCC 86, 87, or 88-Acute Myocardial Infarction; HCC 96-Specified Heart Arrhythmias; HCC 99 or 100-Stroke; HCC 106-Atherosclerosis of the Extremities; HCC 107 or 108-Vascular Disease with Complications; HCC 111-Chronic Obstructive Pulmonary Disease; HCC 157 or 158-Pressure Ulcer of Skin with Necrosis; HCC 173-Amputations; HCC 186-Organ Transplant.
↵c Statistically significant at the .01 level.
↵d Statistically significant at the .05 level.
↵e The reversed Bice-Boxerman Continuity-of-Care Index measures care fragmentation by capturing the number of practitioners providing ambulatory services to a beneficiary and the percentage of care each practitioner provides. Scores ≥0.85 indicate highly fragmented care.
↵f HCC scores are a measure of risk for subsequent expenditures. The Centers for Medicare and Medicaid Services calculates them such that the average for the Medicare fee-for-service population nationally is 1.0. A patient with a risk score of 1.30 is predicted to have expenditures that would be approximately 30% greater than the average, whereas a patient with a risk score of 0.70 is expected to have expenditures that would be approximately 30% less than the average. In our regression model, we also included the percentage of attributed beneficiaries with an assigned HCC score that is derived from CMS’ new enrollee model.
↵g Data source: 2017 Medicare Data on Provider Practice and Specialty.
↵h Data source: 2017 Medicare claims data.
↵i Data source: 2016 SK&A.
↵j Data source: 2016 National Plan and Provider Enumeration System.
↵k Data source: 2016 Master Data Management system 2016.
↵l Data sources: 2016 NCQA, 2016 TJC, 2016 AAAHC, 2016 URAC, state-specific sources 2016; CPC+ data; CMS 2016.
↵m Data source: CMS 2016.
↵n The mapping of 3 states to US Census regions was slightly modified for the selection of a comparison group for the CPC+ evaluation to more closely mirror the CPC+ regions’ market characteristics.
↵o Data source: 2016 Area Health Resource File.
↵p Data source: 2015 Medicare Geographic Variation data.